CONTEXT: It is useful to periodically update the estimate
of the unmet need for contraception in the developing world and other regions
of interest. National surveys since 1990 permit the calculation of estimates
based on the standard definition used in the Demographic and Health Survey
series, as well as alternative definitions.
METHODS: Fifty-five national surveys are used to estimate
numbers and proportions of women with unmet need, according to marital
status, spacing and limiting purposes, age and region.
RESULTS: In the developing world, an estimated 105.2 million
married women have an unmet need. Unmarried women add 8.4 million, and
the former Soviet republics add 9.1 million (of all marital statuses),
for a total of 122.7 million. The proportion of married women in the developing
world with an unmet need is 17%, lower than previously estimated because
of a declining trend in many countries that reflects growing contraceptive
use. For unmarried women, the proportion is 3%. Women aged 15-24 account
for one-third of unmet need. Many women classified as having unmet need
do not plan to use a method, but they are generally offset by women who
want a child within two years yet still plan to use.
CONCLUSIONS: The unmet need numbers reflect the upward
pressures of population growth acting against the downward push of declining
proportions with unmet need. The total estimate of 122.7 million women
with unmet need represents a substantial and continuing challenge for agencies
and governments concerned with ensuring access to contraceptives.
We offer here an updated estimate, as of 2000, of the unmet need for
contraception in the developing world and in the former Soviet republics.
The exercise is limited to numbers and proportions of women in need, as
estimated from survey data. We focus on married and unmarried women, on
youth aged 15-19 and 20-24, and on the implications of broadened definitions
of unmet need.
METHODS AND DATA SOURCES
Surveys conducted since 1990--predominantly as part of the Demographic
and Health Survey (DHS) series or by the Division of Reproductive Health
of the U.S. Centers for Disease Control and Prevention--cover women in
most of the developing world. Of the 55 surveys used for this analysis,
17 took place from 1990 to 1994, and 38 in 1995 or later (see appendix
). A total of 115 countries are covered in the estimates, including all
developing countries with a population of more than one million, except
those where unmet need by the DHS definition* is negligible: China (including
Hong Kong), Singapore, Taiwan and the Republic of Korea. For countries
without surveys, we assumed that the proportion of women with unmet need
was equal to the average (unweighted) proportion with unmet need among
countries in the same region for which information was available. (Countries
with surveys account for 85% of unmet need in Asia, 90% in the Central
Asian republics, 67% in Latin America, 52% in North Africa and the Middle
East, and 83% in Sub-Saharan Africa.) Overall, 80% of estimated global
unmet need comes from countries with information, since most large countries
have recently been surveyed.
Wherever possible, we developed separate estimates for currently married
(including cohabiting), never-married and previously married women, and
for women aged 15-19 and 20-24, as well as those aged 15-49. To estimate
the numbers with unmet need, we applied the proportions of women with unmet
need to the number of women in each subgroup by age or marital status.
Global and Regional Estimates
An estimated 113.6 million women in the developing world have an unmet
need for contraception--105.2 million married women (of whom 55.4 million
wish to space births and 49.8 million wish to limit further childbearing)
and 8.4 million unmarried women (Table 1 ).
In addition, an estimated nine million women in other regions have an unmet
need: 4.6 million in Russia, 3.6 million in eastern Europe, 0.6 million
in the Caucasus and 0.2 million in the Baltic republics. Thus, a total
of 122.7 million women in developing countries and the former Soviet republics
have an unmet need for contraception. (These figures omit users of traditional
methods, who are quite numerous in the former Soviet Union and elsewhere.)
Asia contains 61 million married women with unmet need, or 58% of the
total for the developing world, reflecting the inclusion of several countries
with very large populations (India, Indonesia, Pakistan and Bangladesh).
Sub-Saharan Africa contains 24 million (22% of the total), mostly because
of the large populations of Nigeria, Ethiopia, South Africa and the Democratic
Republic of the Congo. Latin America contributes 11 million married women
with unmet need (11%), nearly half of whom live in Mexico and Brazil. North
Africa and the Middle East account for only about eight million (8%), and
the Central Asian republics, with their smaller populations, have a total
of 1.1 million (1%).
In the developing world as a whole, the prevalence of unmet need among
married women is about equally accounted for by women who wish to space
and those who wish to limit births, but important variations exist. In
Sub-Saharan Africa, 65% of unmet need is for spacing; in Latin America,
by contrast, only 42% is (not shown). In Asia, spacing and limiting needs
are nearly equal. Such differences call for different kinds of contraceptive
supplies and different budgetary considerations.
Unmarried women add to unmet need, accounting for 7% of the developing
world total (not shown). By region, however, this proportion varies widely--from
4% in Asia to 16% in Sub-Saharan Africa. Low proportions reflect that unmarried
women tend not to be sexually active or tend to practice contraception
if they are having intercourse. Only for Sub-Saharan Africa is information
available separately for never-married women (2.6 million) and previously
married women (1.9 million). In that region, 85% of unmet need among never-married
women is for spacing, since most of these women are young. Among previously
married women, who are mainly older and have had more children, only 42%
of unmet need is for spacing. Contraceptive use among adolescents, which
is surprisingly high in some countries (15% in Botswana, 23% in Togo and
27% in Cameroon), somewhat reduces unmet need among unmarried women.
The proportion of currently married women with unmet need in various
regions of the developing world in 2000 ranges from 11% to 24% (Table
1). Sub-Saharan Africa's figure of 24% is about half again the average
for the developing world overall (17%); other regional figures range from
11% in the Central Asian republics to 14% in Latin America and 16% in North
Africa and the Middle East and in Asia. The most recent estimate for three
of the four regions is well below the estimate for 1996 (see below). Country-specific
declines identified in recent surveys reflect growth in the proportions
of couples using modern methods, which shrinks the residual group still
having an unmet need.
For unmarried women in the developing world, the proportion with unmet
varies by region around the overall figure of 3%, ranging from 1% to 10%.
Comparisons with Earlier Estimates
Other estimates of unmet need have often cited 120 million, referring just
to women who are currently married, and just to the developing world. That
figure is probably based on a computation in the early 1990s that extrapolated
population-weighted data from 50 surveys in developing countries to other
countries.1 Other work estimated an upper limit of 150 million,2 but it
included all traditional method users, as well as an estimate for the entire
Soviet Union that also included traditional method users;3 in effect, this
work estimated unmet need for modern contraception. A much broader definition
was developed to include the usual DHS categories and women who especially
need protection against pregnancy because their age, high parity or short
birth intervals would increase their risk of poor outcomes.4 This change
considerably elevated the proportions of women with unmet need in 28 countries
where DHS conducted surveys from 1985 to 1990. Another study used the 1987
Sri Lanka DHS to explore a variety of health-based definitions, obtaining
greatly enlarged proportions with unmet need under certain definitions.5
For currently married women in the developing world, the estimate of
105.2 million with unmet need represents only a small increase in recent
years. An estimate prepared from 45 similar surveys in 1996, excluding
not only China but also Central Asia, showed 101.7 million married women
with unmet need (Table 2).6 When Central
Asia is excluded from our total, the current estimate is 104.1 million,
or just 2% more than the 1996 estimate. The difference reflects considerable
growth in the population base, since the proportions with unmet need have
declined, as documented in repeated surveys within numerous countries.7
(As we have noted, these declining proportions are assigned also to countries
lacking surveys, under the assumption that they share the known trend.)
Population growth has been substantial: According to the UN estimates,
in the developing world outside of China, the number of women aged 15-49
grew by 13% between 1995 and 2000.
Overall, however, the proportion in need fell from 19% to 17%. Declines
have had to be quite substantial, especially in the larger countries, to
more than offset the growth in the number of women of reproductive age.
India, for example, showed a decline in unmet need from 16.5% to 15.8%
between the 1992-1993 and 1998-1999 national surveys. That translates to
a reduction of more than 2.5 million women. Another, minor influence that
might tend to lower the proportion with unmet need is that the UN has reduced
its estimates of the number of women aged 15-49. However, the reductions
are very small--less than 1% between the 1996 and 1998 estimates for the
developing world outside of China, only 4% for Sub-Saharan Africa and nearly
zero for the other regions (except Latin America, which showed a slight
increase). The UN estimates for 2000 show a further reduction of 1% in
the number of women 15-49.
Estimates for Women Aged 15-19 and 20-24
Because of the special importance of young women, we have extracted data
on those aged 15-19 and 20-24 for special attention. Information is available
for currently married women in these age-groups in all regions (Table
3 ), but data on unmarried women at those ages are severely limited,
except in Sub-Saharan Africa. (There, among never-married women, the proportion
with unmet need is 7% at ages 15-19 and 11% at ages 20-24; among previously
married women, the proportions are 15% and 16%, respectively.)
These two age-groups account for 33% of unmet need among married women
(not shown), or 34.9 million women. The proportion falls well below the
average in North Africa and the Middle East (23%), as well as in the Central
Asian republics (28%). For Sub-Saharan Africa, the figure is 31%; for Latin
America, 31%; and for Asia, 35%. Young married women represent a surprisingly
large group and deserve careful program attention. They tend to be at low
parities, but many are interested in limiting births.
Teenagers outnumber women in their early 20s but are less likely to
be married or cohabiting; therefore, the 20-24 age-group contains twice
the number in need (23.5 vs. 11.4 million--Table
3 ). The differential is even more extreme in North Africa and the
Middle East and in Central Asia. It is slightly less marked in Sub-Saharan
Africa because cohabitation begins earlier there and the entire 15-19 age-group
is considerably larger in relation to the 20-24 age-group than it is elsewhere.
Within each region, the two young age-groups have similar proportions
with an unmet need, except in Latin America (Table
3 ). When regions are compared, the combined proportion for the two
age-groups in Central Asia (16%) is similar to that in North Africa and
the Middle East (18%), and the combined proportion in Asia (23%) is similar
to that in Sub-Saharan Africa (26%).
From Tables 1 and 3, we see that for both young married women and all
married women, Sub-Saharan Africa has the highest proportion with unmet
need--about one in four for both groups. However, the other regions show
differences: Young women have more unmet need by a considerable margin
in Latin America (22% vs. 14%), in Asia (23% vs. 16%) and in the Central
Asian republics (16% vs. 11%), but by rather little in North Africa and
the Middle East (18% vs. 16%).
All estimates of unmet need would be considerably larger under the assumption
that users of traditional methods have an unmet need for modern methods.
Traditional methods usually have high failure rates, resulting in numerous
unwanted pregnancies, abortions, maternal deaths and births. In the former
Soviet republics, where modern methods have been largely unavailable, the
inclusion of traditional method users would more than double the numbers
with unmet need. In eastern Europe, the number would increase from 3.6
million to 9.9 million; in Russia (whose population is about equal to that
of the rest of eastern Europe), from 4.6 million to 9.6 million. In one
sense, there remains an unmet need wherever contraceptive technology is
faulty and users rely on defective methods for lack of better alternatives.
For clarity, however, the alternative definitions used should be made fully
It may be argued that the inclusion of traditional method users is undesirable,
since it implies that unmet need should relate to the use of highly effective
contraception. Indeed, the DHS definition excludes women who became pregnant
accidentally while using a method, since they were merely in need of better
contraception, not any contraception. The counterargument is that when
the technology is imperfect, resulting in unwanted pregnancies, a true
residual unmet need remains. Because traditional method users are of proven
motivation, are at risk of unwanted pregnancies and are numerous in many
countries, they should not be ignored, especially since a poor service
environment is often responsible for their lack of access to more effective
An entirely different issue is that the DHS definition of unmet need
omits amenorrheic women who say they wanted the last birth, regardless
of their intentions regarding a future birth. Action programs wishing to
offer information and services to all women who want to postpone pregnancy
require inclusive estimates, especially since delayed assistance often
means an unwanted early conception that results in an unsafe abortion or
an unwanted child. Substantial proportions of births occur before they
are wanted and soon after the previous birth, creating a high-risk situation
for the mother and infant.8 Nearly all amenorrheic women say in surveys
that they wish to delay their next pregnancy or birth, but among such women,
the DHS definition captures only those who say the last birth was mistimed
Analyses of 27 DHS surveys illustrate the impact of including women
with postpartum amenorrhea:9 In these 27 countries, the proportion of married
women with unmet need would increase by roughly half, from 22% to 33% (Table
4). In Sub-Saharan Africa, where spacing is dominant in most countries,
the increase in the unmet need estimate is quite marked, from 26% to 43%.
A separate tabulation for the spacing and limiting groups confirms this
pattern (not shown).
The new estimate of 122.7 million women with unmet need reflects declines
in the proportions with unmet need in many countries; additional declines
have probably occurred since the surveys were conducted in the 1990s (see
Appendix Table 1 , page 142.) A further consideration
is that the latest (2000) UN estimate for women aged 15-49 in the developing
world outside of China is 1% below the 1998 UN estimate used here, which
would slightly reinforce a reduced global total for unmet need.
The global figure allows for unmet need among unmarried women in all
regions and includes approximate figures for all former Soviet republics.
It does not include users of traditional methods, even though these users
are quite numerous in many countries. The alternative definitions of unmet
need offered here and elsewhere would enlarge the global figure.
Also excluded are unknown numbers of persons in need of contraceptive
protection in China and a few other Asian countries with near-ceiling contraceptive
use and low fertility. Given China's size, it undoubtedly contains a substantial
subgroup of women who are sexually active, lack contraceptive protection
and do not want to become pregnant, especially if the women are unmarried
adolescents. (This is true also in the United States and elsewhere in the
West.) In addition, needs exist among women who have had recent abortions
and are not otherwise accounted for, and among men who are not associated
with female survey respondents or who, if surveyed, would report an unmet
need when their female partner would not.
In surveys, some women listed as having an unmet need say they will
not use a method; in one compilation of 39 national surveys,10 an average
of 61% of women with unmet need (26-83% at the country level) say they
do not intend to use a method. However, the same surveys make clear that
these women are generally balanced by many others who want a birth within
two years (and so are classified by DHS as not having an unmet need) but
who say they intend to use a method within the next year.
The overall proportion of couples with unmet need has fallen slightly
as contraceptive use has increased, even though desired family size is
now below earlier levels. The proportion remains substantial, however,
and the population base has grown. Millions are still without protection
against pregnancies that they do not want.
APPENDIX: TECHNICAL NOTES
The surveys used in this study (see Appendix Table 1 )
provide the proportions of women with unmet need; the numbers of women
aged 15-49, 15-19 and 20-24 are 1998 UN estimates. The proportions in each
marital-status category come from the UN database on marriage patterns;
from U.S. Census Bureau estimates; and from Ross J, Stover J and Willard
A, Profiles for Family Planning and Reproductive Health Programs, Glastonbury,
CT, USA: The Futures Group International, 1999. Special tabulations of
DHS surveys were made to obtain estimates of unmet need among never-married
and previously married women, and among women aged 15-19 and 20-24.
• Marital status. Estimates of unmet need for women who
are currently married or in union are available from all 55 surveys. Surveys
including unmarried (never-married and previously married) women are available
only for Sub-Saharan Africa and for Latin America and the Caribbean; some
of the latter (those conducted by the Division of Reproductive Health,
U.S. Centers for Disease Control and Prevention) depart from the DHS definition
by omitting unmet need among pregnant and amenorrheic women. Surveys covering
unmarried women are not available for Asia (except the Philippines) or
for North Africa and the Middle East. The proportion of unmarried women
with unmet need is probably small in both regions, but the absolute numbers,
especially in Asia, may be large. After reviewing the few fragmentary studies
available and considering the rather low estimates in Latin America and
the Caribbean, we decided to use an assumption that 2% of unmarried women
in Asia and in North Africa and the Middle East had an unmet need for contraception.
More unmarried women than this are sexually active (even by the narrow
DHS standard of sexual activity in the last month), but some practice contraception,
some are infecund and some want a child within two years.
• Eastern Europe and the Russian Federation. The United
Nations lists 10 countries in eastern Europe. National surveys are available
for six of these: Bulgaria, Czech Republic, Hungary, Moldova, Romania and
Ukraine. Applying the average unweighted proportion with unmet need in
these six to three countries with no surveys (Belarus, Poland and Slovakia)
produces an overall estimate of 3.6 million women with unmet need. For
the 10th, Russia, comparable surveys exist only for three major cities;
letting these represent the urban sector and taking the rural-urban ratio
from the six other surveys produces an estimate of 4.8 million women in
unmet need for all of Russia.
• Caucasus and Baltic republics. The following proportions
of women with unmet need, from the Georgia survey, were applied to Azerbaijan
and Armenia (for which survey data have recently become available): 0.1%
for never-married women, 4.4% for those previously married and 21.3% for
those currently married or in union. Currently married women represent
98% of the final total. For the Baltic republics, the unweighted average
from surveys in Latvia and Lithuania was applied to Estonia.
John A. Ross is senior fellow, The Futures Group International,
Glastonbury, CT, USA; William L. Winfrey is senior research scientist,
The Futures Group International, Washington, DC.
1. Calculation by Richard Blackburn, Johns Hopkins University
Population Information Program, cited in Robey B, Rutstein S and Morris
L, The fertility decline in developing countries, Scientific American,
Dec. 1993, pp. 60-67; and Robey B, Rutstein S and Morris L, The reproductive
revolution: new survey findings, Population Reports, 1992, Series M, No.
2. U.S. Agency for International Development, Unmet Need
for Family Planning, POP BRIEFS, Sept. 1998.
3. Rutstein S, Macro International, Calverton, MD, USA,
personal communication, Dec. 18, 2000.
4. Govindasamy P et al., High-Risk Births and Maternity
Care, Demographic and Health Survey Comparative Studies, Columbia, MD,
USA: Macro International, 1993, No. 8.
5. DeGraff DS and de Silva V, A new perspective on the
definition and measurement of unmet need for contraception, International
Family Planning Perspectives, 22(4):140-147, 1996.
6. Robey B, Ross J and Bhushan I, Meeting unmet need:
new strategies, Population Reports, 1996, Series J, No. 43, pp. 1-35.
7. Westoff CF, Unmet Need at the End of the Century, Demographic
and Health Surveys Comparative Reports, Calverton, MD, USA: Macro International,
2001, No. 1.
8. Hobcraft J, Child spacing and child mortality, in:
Institute for Resource Development (IRD)/Macro International, Proceedings
of the Demographic and Health Surveys World Conference, Washington, DC,
1991, vol. 2, Columbia, MD, USA: IRD/Macro International, 1991, pp. 1157-1181;
and Hobcraft J, The Health Rationale for Family Planning: Timing of Births
and Child Survival, New York: United Nations, 1994.
9. Ross J and Winfrey W, Contraceptive use, intention
to use and unmet need during the extended postpartum period, International
Family Planning Perspectives, 2001, 27(1):20-33.
10. Ross J, Stover J and Willard A, Profiles for Family
Planning and Reproductive Health Programs: 116 Countries, Glastonbury,
CT, USA: The Futures Group International, 1999, Table A.15, p. A.71.
We are grateful to Kate Abel and Rena Geibel of The Futures
Group International for assistance with data processing and analysis. Financial
support was received from the POLICY II project of the Futures Group International
and from the Population, Health, and Nutrition Information Project (PHNIP).
Staff of Macro International provided special tabulations for certain countries.
We thank the U.S. Agency for International Development for its financial
support of all of these activities.
* According to the DHS definition, a woman
has an unmet need for contraception if she is fecund, sexually active and
not using any contraceptive method, and does not want a child for at least
two years. If a woman is pregnant or amenorrheic after giving birth, she
is considered to have an unmet need if she had not wanted the pregnancy
or birth either when it occurred or ever. Fine points of the definition
have changed over the years, but the result has been only small quantitative
differences. See, for example, Westoff CF and Bankole A, Unmet Need: 1990-1994,
Demographic and Health Surveys Comparative Studies, Calverton, MD, USA:
Macro International, 1995, No. 16, pp. 3-4; and reference 7.